DALFAMPRIDINE ER 10 MG TABLET ER 12H [Ampyra] (60 TABLETS ) (NDC: 65862086360)
2021 Medicare Prescription Drug Plan (MAPD) Information
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Plan Name |
Monthly Prem. |
De- duct- ible | Does Plan Offer Additional Gap Coverage | Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Plan’s Avg. Retail Drug Price 30-Day |
Tier Nbr. |
Tier Desc. |
30-Day Prfrd. Pharm |
90-Day Mail Order |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | P | $164.40 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$250 | No | 5 |
Specialty Tier |
28% | n/a | P | $153.00 |
Browse Plan Formulary |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$395* | No | 2* |
Generic |
$15.00 | $37.50 | P Q:60 /30Days | $547.20 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$295 | No | 5 |
Specialty Tier |
27% | n/a | P Q:60 /30Days | $1,489.20 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$295 | No | 5 |
Specialty Tier |
27% | n/a | P Q:60 /30Days | $1,518.60 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$295 | No | 5 |
Specialty Tier |
27% | n/a | P Q:60 /30Days | $1,502.40 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$295 | No | 5 |
Specialty Tier |
27% | n/a | P Q:60 /30Days | $1,513.80 |
Browse Plan Formulary |
EmblemHealth VIP Part B Saver (HMO)
|
$0.00 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $1,494.00 |
Browse Plan Formulary |
EmblemHealth VIP Reserve (HMO)
|
$0.00 |
$295 | No | 5 |
Specialty Tier |
27% | n/a | P Q:60 /30Days | $1,489.20 |
Browse Plan Formulary |
Empire MediBlue HealthPlus (HMO)
|
$0.00 |
$350 | No | 5 |
Specialty Tier |
26% | n/a | P Q:60 /30Days | $1,464.60 |
Browse Plan Formulary |
Empire MediBlue Select (HMO)
|
$0.00 |
$350 | No | 5 |
Specialty Tier |
26% | n/a | P Q:60 /30Days | $1,464.60 |
Browse Plan Formulary |
|
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 | No | 2 |
Generic |
$20.00 | $40.00 | P | $588.00 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$350 | No | 3 |
Preferred Brand |
$47.00 | $47.00 | P | $642.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Healthfirst Signature (HMO)
|
$0.00 |
$350 | No | 3 |
Preferred Brand |
$47.00 | $47.00 | P | $642.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H3533-027 (HMO)
|
$0.00 |
$400 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | P Q:60 /30Days | $600.00 |
Browse Plan Formulary |
HumanaChoice H5970-024 (PPO)
|
$0.00 |
$350* | No | 3* |
Preferred Brand |
$47.00 | $131.00 | P Q:60 /30Days | $600.00 |
Browse Plan Formulary |
HumanaChoice H5970-024 (PPO)
|
$0.00 |
$350* | No | 3* |
Preferred Brand |
$47.00 | $131.00 | P Q:60 /30Days | $600.00 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Montefiore + Oscar Easy Care (HMO)
|
$0.00 |
$0 | No | 2 |
Generic |
$0.00 | $0.00 | P | $758.40 |
Browse Plan Formulary |
PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 1 |
Tier 1 |
0% | 0% | P Q:60 /30Days | $107.40 |
Browse Plan Formulary |
WellCare Absolute (PPO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | P | $627.00 |
Browse Plan Formulary |
WellCare Choice (HMO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $94.00 | P | $627.00 |
Browse Plan Formulary |
WellCare Element (HMO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $94.00 | P | $627.00 |
Browse Plan Formulary |
WellCare Today's Options Advantage Plus 550B (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $74.00 | P | $627.00 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
WellCare Summit (PPO)
|
$5.10 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $94.00 | P | $627.00 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$10.90 |
$445* | No | 2* |
Generic |
$20.00 | $40.00 | P | $588.00 |
Browse Plan Formulary |
WellCare Compass (HMO)
|
$12.30 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $94.00 | P | $627.00 |
Browse Plan Formulary |
WellCare Imperial (PPO D-SNP)
|
$12.50 |
$445 | No | 3 |
Preferred Brand |
$45.00 | $90.00 | P | $627.00 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$16.00 |
$350 | No | 5 |
Specialty Tier |
26% | n/a | P Q:60 /30Days | $1,572.00 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$16.00 |
$350 | No | 5 |
Specialty Tier |
26% | n/a | P Q:60 /30Days | $1,445.40 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Empire MediBlue Plus (HMO)
|
$16.00 |
$350 | No | 5 |
Specialty Tier |
26% | n/a | P Q:60 /30Days | $1,454.40 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)
|
$16.00 |
$300 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $153.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H3533-032 (HMO)
|
$21.00 |
$200 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | P Q:60 /30Days | $600.00 |
Browse Plan Formulary |
Humana Gold Plus H3533-032 (HMO)
|
$21.00 |
$200 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | P Q:60 /30Days | $600.00 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO D-SNP)
|
$21.60 |
$445 | No | 2 |
Generic |
$10.00 | $20.00 | P | $501.60 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO D-SNP)
|
$22.30 |
$445 | No | 2 |
Generic |
$7.00 | $14.00 | P | $463.20 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Fidelis Dual Advantage (HMO D-SNP)
|
$22.50 |
$445 | No | 2 |
Generic |
$20.00 | $40.00 | P | $501.60 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
|
$25.30 |
$445* | No | 3* |
Preferred Brand |
$47.00 | $94.00 | P | $423.60 |
Browse Plan Formulary |
Aetna Medicare Assure Plan (HMO D-SNP)
|
$25.70 |
$190 | No | 5 |
Specialty Tier |
29% | n/a | P | $164.40 |
Browse Plan Formulary |
WellCare Access (HMO D-SNP)
|
$27.10 |
$445 | No | 3 |
Preferred Brand |
$40.00 | $80.00 | P | $627.00 |
Browse Plan Formulary |
Elderplan Plus Long Term Care (HMO D-SNP)
|
$31.80 |
$445 | No | 1 |
Tier 1 |
15% | 15% | P | $423.60 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
|
$32.60 |
$445 | No | 3 |
Tier 3 |
25% | 25% | Q:60 /30Days | $153.00 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AARP Medicare Advantage Plan 2 (HMO)
|
$34.00 |
$395 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $154.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Elderplan For Medicaid Beneficiaries (HMO D-SNP)
|
$35.40 |
$445 | No | 1 |
Tier 1 |
15% | 15% | P | $423.60 |
Browse Plan Formulary |
Elderplan Advantage For Nursing Home Residents (HMO I-SNP)
|
$35.50 |
$445 | No | 1 |
Tier 1 |
25% | 25% | P | $423.60 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO)
|
$35.60 |
$275 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $153.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Nursing Home Plan 2 (HMO I-SNP)
|
$35.90 |
$445 | No | 3 |
Tier 3 |
25% | 25% | Q:60 /30Days | $153.00 |
Browse Plan Formulary |
Aetna Medicare Elite Plan 2 (PPO)
|
$39.00 |
$300 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
27% | n/a | P | $136.20 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Plus SNP-DE H3533-031 (HMO D-SNP)
|
$40.30 |
$435 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | P Q:60 /30Days | $600.00 |
Browse Plan Formulary |
AgeWell New York Advantage Plus (HMO D-SNP)
|
$42.30 |
$445 | No | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:60 /30Days | $277.20 |
Browse Plan Formulary |
AgeWell New York CareWell (HMO I-SNP)
|
$42.30 |
$445 | No | 5 |
Tier 5 |
25% | 25% | P Q:60 /30Days | $277.20 |
Browse Plan Formulary |
AgeWell New York FeelWell (HMO D-SNP)
|
$42.30 |
$445 | No | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:60 /30Days | $277.20 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$42.30 |
$350 | No | 5 |
Specialty Tier |
26% | 26% | P Q:60 /30Days | $277.20 |
Browse Plan Formulary |
ArchCare Advantage (HMO I-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
25% | 25% | P | $722.40 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Centers Plan for Dual Coverage Care (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
15% | 15% | P Q:60 /30Days | $610.20 |
Browse Plan Formulary |
Centers Plan for Nursing Home Care (HMO I-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
25% | 25% | P Q:60 /30Days | $557.40 |
Browse Plan Formulary |
Elderplan Assist (HMO I-SNP)
|
$42.30 |
$445* | No | 3* |
Preferred Brand |
$47.00 | $94.00 | P | $423.60 |
Browse Plan Formulary |
EmblemHealth VIP Assist (HMO D-SNP)
|
$42.30 |
$445 | No | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:60 /30Days | $1,494.00 |
Browse Plan Formulary |
EmblemHealth VIP Connect (HMO D-SNP)
|
$42.30 |
$445 | No | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:60 /30Days | $1,494.00 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.30 |
$445 | No | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:60 /30Days | $1,489.20 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.30 |
$445 | No | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:60 /30Days | $1,503.00 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.30 |
$445 | No | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:60 /30Days | $1,514.40 |
Browse Plan Formulary |
EmblemHealth VIP Dual Reserve (HMO D-SNP)
|
$42.30 |
$445 | No | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:60 /30Days | $1,489.20 |
Browse Plan Formulary |
EmblemHealth VIP Dual Select (HMO D-SNP)
|
$42.30 |
$445 | No | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:60 /30Days | $1,494.60 |
Browse Plan Formulary |
EmblemHealth VIP Passport NYC (HMO)
|
$42.30 |
$295 | No | 5 |
Specialty Tier |
27% | n/a | P Q:60 /30Days | $1,489.20 |
Browse Plan Formulary |
EmblemHealth VIP Solutions (HMO D-SNP)
|
$42.30 |
$445 | No | 5 |
Tier 5 |
15% | 15% | P Q:60 /30Days | $1,494.00 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$42.30 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $1,470.00 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage Select (HMO D-SNP)
|
$42.30 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $1,472.40 |
Browse Plan Formulary |
Empire MediBlue Extra Select (HMO)
|
$42.30 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $1,464.60 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Advantage (HMO D-SNP)
|
$42.30 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $1,471.20 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Connect (HMO D-SNP)
|
$42.30 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $1,471.20 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Plus (HMO D-SNP)
|
$42.30 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $1,471.20 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Hamaspik Medicare Choice (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
15% | 15% | P Q:60 /30Days | $108.00 |
Browse Plan Formulary |
Hamaspik Medicare Select (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
15% | 15% | P Q:60 /30Days | $109.20 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | P | $642.60 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
25% | 25% | P | $642.60 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | P | $642.60 |
Browse Plan Formulary |
Integra Balanced Medicaid Advantage (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | P Q:60 /30Days | $321.60 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Integra Harmony (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
15% | 15% | P Q:60 /30Days | $321.60 |
Browse Plan Formulary |
Integra Synergy Medicaid Advantage Plus (MAP) (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | P Q:60 /30Days | $321.60 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
25% | n/a | Q:60 /30Days | $90.60 |
Browse Plan Formulary |
MetroPlus Advantage Plan (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
15% | 15% | P | $433.80 |
Browse Plan Formulary |
MetroPlus UltraCare (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | P | $433.80 |
Browse Plan Formulary |
Montefiore + Oscar Extra Benefits (HMO)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
25% | 25% | P | $758.40 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
RiverSpring MAP (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
15% | 15% | P | $1,687.20 |
Browse Plan Formulary |
RiverSpring Star (HMO I-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
25% | 25% | P | $1,687.20 |
Browse Plan Formulary |
Senior Whole Health of New York NHC (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
15% | 15% | P Q:60 /30Days | $1,509.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$42.30 |
$445 | No | 3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $153.00 |
Browse Plan Formulary |
VillageCareMAX Medicare Health Advantage (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
15% | 15% | P Q:60 /30Days | $107.40 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO D-SNP)
|
$42.30 |
$445 | No | 2 |
Generic |
$19.00 | $57.00 | P Q:60 /30Days | $130.80 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO)
|
$43.70 |
$150 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $153.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
EmblemHealth VIP Rx Saver (HMO)
|
$49.00 |
$395 | No | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $1,515.00 |
Browse Plan Formulary |
EmblemHealth VIP Rx Saver (HMO)
|
$49.00 |
$395 | No | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $1,504.20 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 1 (HMO)
|
$54.00 |
$395 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $154.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
EmblemHealth VIP Go (HMO-POS)
|
$72.00 |
$250 | No | 5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $1,493.40 |
Browse Plan Formulary |
EmblemHealth VIP Go (HMO-POS)
|
$72.00 |
$250 | No | 5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $1,502.40 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Aetna Medicare Premier Plan (PPO)
|
$76.00 |
$250 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | P | $136.20 |
Browse Plan Formulary |
WellCare Preferred (HMO)
|
$81.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | P | $627.00 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$96.00 |
$200 | No | 5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $1,489.20 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$96.00 |
$200 | No | 5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $1,518.60 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$96.00 |
$200 | No | 5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $1,502.40 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$96.00 |
$200 | No | 5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $1,513.80 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Centers Plan for Medicaid Advantage (HMO D-SNP)
|
$101.00 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | P Q:60 /30Days | $610.20 |
Browse Plan Formulary |
Centers Plan for Medicaid Advantage Plus (HMO D-SNP)
|
$101.00 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | P Q:60 /30Days | $628.20 |
Browse Plan Formulary |
VillageCareMAX Medicare Total Advantage (HMO D-SNP)
|
$116.00 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | P Q:60 /30Days | $107.40 |
Browse Plan Formulary |
MetroPlus Platinum Plan (HMO)
|
$148.50 |
$445 | No | 1 |
Tier 1 |
25% | 25% | P | $433.80 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$302.00 |
$200 | No | 5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $1,493.40 |
Browse Plan Formulary |